Reaching the full preventive potential of HIV pre-exposure prophylaxis
Authors: Liza Coyer, Elske Hoornenborg
Journal: The Lancet Public Health (2022)

Despite decreases in HIV incidence, too many people still acquire HIV. In Europe, 104 765 new HIV infections were diagnosed in 2020.1European Centre for Disease Prevention and Control/WHO Regional Office for EuropeHIV/AIDS surveillance in Europe 2021 (2020 data).https://www.ecdc.europa.eu/sites/default/files/documents/2021-Annual_HIV_Report_0.pdfDate: Nov 30, 2021Date accessed: April 26, 2022Google Scholar Oral HIV pre-exposure prophylaxis (PrEP) is a crucial strategy to reach the UNAIDS goals for the global AIDS response.2UNAIDSUnderstanding fast-track: accelerating action to end the AIDS epidemic by 2030.https://digitallibrary.un.org/record/3948651?ln=enDate: 2015Date accessed: April 26, 2022Google Scholar A majority of countries in North America and western and central Europe have been gradually rolling out PrEP since 2012.3PrEPWatchThe Global PrEP Tracker. Number of PrEP initiations by geography across time until Q1 2022.https://data.prepwatch.org/Date: March 2022Date accessed: April 26, 2022Google Scholar PrEP has an efficacy of up to 99% for preventing HIV infection if taken correctly and effectiveness was high in demonstration studies, but population-level effectiveness has been estimated in only few studies that were small-scale.4Fonner VA Dalglish SL Kennedy CE et al.Effectiveness and safety of oral HIV preexposure prophylaxis for all populations.AIDS. 2016; 30: 1973-1983Crossref PubMed Scopus (505) Google Scholar, 5Pagkas-Bather J Khosropour CM Golden MR Thibault C Dombrowski JC Population-level effectiveness of hiv pre-exposure prophylaxis among MSM and transgender persons with bacterial sexually transmitted infections.J Acquir Immune Defic Syndr. 2021; 87: 769-775Crossref PubMed Scopus (5) Google Scholar, 6Johnson KA Hessol NA Kohn R et al.HIV Seroconversion in the era of pharmacologic prevention: a case-control study at a San Francisco STD clinic.J Acquir Immune Defic Syndr. 2019; 82: 159-165Crossref PubMed Scopus (5) Google Scholar Hugo Jourdain and colleagues7Jourdain H Billioti de Gage S Desplas S Dray-Spira R Real-world effectiveness of pre-exposure prophylaxis in men at high risk of HIV infection in France: a nested case-control study.Lancet Public Health. 2022; 7: e529-e536Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar report their timely assessment of real-world PrEP effectiveness in France, the first European country to reimburse users for PrEP from 2016 onwards. Using data from the French National Health Data System, which covers more than 99% of the French population, Jourdain and colleagues did a matched, nested case-control study among adult men identified as being at high risk of sexually-acquired HIV infection between Jan 1, 2016, and June 30, 2020. Among 46 706 individuals, 256 cases with a newly-diagnosed HIV infection up to Dec 1, 2020, were matched to 1213 controls. 29% of cases used PrEP compared with 49% of controls, resulting in an overall reduction of 60% (95% CI 46–71) in the odds of HIV infection. Results from this study corroborate previous findings that PrEP prevents HIV infections, especially in people with high consumption. However, the overall PrEP effectiveness of 60% is worryingly low and signifies that PrEP is not taken well enough. Indeed, PrEP effectiveness was 93% (95% CI 84–97) in men with a high level of PrEP consumption and 86% (78–92) if excluding periods after PrEP discontinuation. In addition, the results reveal important issues about PrEP accessibility, illustrated by 71% of infections being diagnosed among men who were not using PrEP despite being at high risk of HIV infection and regularly accessing HIV testing services. Furthermore, the 256 new HIV cases represent only a small proportion of the overall number of infections that are diagnosed annually in France, which was 3443 in 2020, of which almost a third were in men who have sex with men.1European Centre for Disease Prevention and Control/WHO Regional Office for EuropeHIV/AIDS surveillance in Europe 2021 (2020 data).https://www.ecdc.europa.eu/sites/default/files/documents/2021-Annual_HIV_Report_0.pdfDate: Nov 30, 2021Date accessed: April 26, 2022Google Scholar It is important to note that in the low-consumption group, in which PrEP effectiveness was only 18%, the authors could not distinguish between infrequent but correct use of on-demand PrEP (ie, use before and after sexual contact) and inadequate adherence to daily PrEP. Adequate assessment of adherence to on-demand PrEP requires comprehensive sexual behaviour data, which were missing from the data source used. However, several studies have determined a high efficacy or effectiveness of on-demand PrEP for men who have sex with men,4Fonner VA Dalglish SL Kennedy CE et al.Effectiveness and safety of oral HIV preexposure prophylaxis for all populations.AIDS. 2016; 30: 1973-1983Crossref PubMed Scopus (505) Google Scholar, 8Molina JM Charreau I Spire B et al.Efficacy, safety, and effect on sexual behaviour of on-demand pre-exposure prophylaxis for HIV in men who have sex with men: an observational cohort study.Lancet HIV. 2017; 4: e402-e410Summary Full Text Full Text PDF PubMed Scopus (270) Google Scholar and offering a choice of PrEP modalities will probably increase uptake and adherence. Furthermore, the absence of sexual behaviour data made the selection of the control group challenging, resulting in an under-representation of men with a high risk of HIV infection who were not accessing sexual health services. Worryingly, the authors showed that PrEP effectiveness was greatly reduced in men younger than 30 years and in those who were socioeconomically deprived, who also had low amounts of PrEP consumption and high rates of PrEP discontinuation. Other studies9Zhang J Li C Xu J et al.Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis.Lancet HIV. 2022; 9: e254-e268Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 10Hojilla JC Hurley LB Marcus JL et al.Characterization of HIV preexposure prophylaxis use behaviors and HIV incidence among US adults in an integrated health care system.JAMA Netw Open. 2021; 4e2122692Crossref PubMed Scopus (11) Google Scholar from various settings are consistent with these findings. As such, structural and personalised interventions are urgently needed to improve accessibility, adherence, and continuation of PrEP in these groups, and to decrease inequities between groups across the PrEP continuum of care. Interventions should be designed together with communities, and should include online PrEP access, support programmes, integrated sexual health care close to communities, accommodation of unscheduled visits, and access to new and long-acting PrEP formulations such as injectable PrEP. Programmes that limit participant numbers or require substantial out-of-pocket costs are likely to further decrease access for young people who become sexually active when PrEP programmes have already reached their maximum capacity and people who are socioeconomically deprived, thus further exacerbating inequities. PrEP prevents HIV infection and empowers people by putting protection from HIV in the hands of the user. Let us make sure that PrEP can reach its full preventive potential. We declare no competing interests. The views expressed here are those of the authors and do not represent those of their institutions. Real-world effectiveness of pre-exposure prophylaxis in men at high risk of HIV infection in France: a nested case-control studyPrEP effectiveness appears to be lower in real-world conditions than is reported in clinical trials. Strengthening efforts to improve the monitoring of PrEP compliance will be essential to ensure PrEP effectiveness, especially among young and socioeconomically deprived recipients. Full-Text PDF Open Access